QUALITY AND AQI

There are risks and costs to a program of action. But they are far less than the long-range risks and costs of comfortable inaction.

-- John F Kennedy

Quality Management in Your Practice

The goal of quality management (QM) is to improve efficiency and outcomes. An entire industry has arisen devoted to making this simple concept complex, and to frustrating hard-working anesthesiologists.  The purpose of this document is to provide an uncluttered approach to creating an anesthesiology QM program.  A QM program will help your group improve patient outcomes, and will make it easier to meet your hospital’s need for outcome data, along with Joint Commission requirements for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE), and ABA requirements for Maintenance of Certification in Anesthesiology (MOCA).

A detailed review of the history, theory and practice of QM can be found in the Manual for Anesthesia Department Organization and Management (MADOM), written by the ASA Committee for Quality Management and Departmental Administration and available to ASA members on the website. For those just starting out, here is a simple 8-step plan:

Step One:  Designate a physician in your group to lead QM efforts.  Successful QM programs depend on a physician champion. This individual should recruit others (a committee) to help with data analysis and peer review, and should engage with QM personnel in the facilities you serve.  The facility has similar QM obligations to your practice, and may have resources (such as dedicated QM nurses) who can help gather data.

Step Two:  Establish a list of indicators for your practice. An indicator is any variable that tells you something about your practice, ranging from how many patients die in the OR to how long it takes the hospital to replace a light bulb in the women’s locker room. Indicators tell you something about your structure (e.g. how many practitioners, how many ORs), your process (e.g. how many patients get perioperative antibiotics), or your outcomes (e.g. how many patients die) Measuring indicators will enable you to engage in the “quality cycle,” which is simple and intuitive:

• Measure what you do
• Make improvements
• Measure again

Appended is the AQI recommended list of indicators.  This is only a starting point, and should be adjusted based on what data is most important to your practice.

Step Three:  Gather data and enter it in a database.  There are commercial products available to assist with this process, but many groups have developed their own electronic tools.  The ASA provides samples in the MADOM chapter, and the AQI provides all sorts of recommendations and referrals on its website.  The purpose of your database is to facilitate analysis and reporting.

Step Four:  Report overall data to your group and to local stakeholders (such as hospital administration). Three concepts are worth noting.  First, some data should be reported as rates: occurrences per opportunities (post-dural puncture headaches per total spinals and epidurals attempted).  Second, data should be presented over time (monthly or quarterly), and gains value when trends can be observed.  Third and finally, some data – especially outcomes – are strongly biased by external factors, and should be risk adjusted prior to public presentation or benchmarked to data gathered under similar conditions.  As an example of all three concepts, anesthetic mortality in a trauma center (the rate of deaths per anesthetic) is presented quarterly (trended over time) and is adjusted for the patients’ severity of injury and benchmarked to mortality from other trauma centers. 

Step Five:  Review unusual events.  Many complications of anesthesia are rare, and thus not suitable for numeric assessment until numbers get very large.  These events should be individually reviewed and discussed by the QM Physician and Committee.  Discussion should focus on what happened and how to prevent it from happening again.  The discussion should be documented:  Keep notes!  When a cluster of events occurs, one response is a ‘focused review’ by a small group of experts, focused on identifying common systematic factors and potential solutions. This, too, should be documented.

Step Six:  Make improvements. Sometimes quality can be improved by presentation of data or discussion of cases (i.e. provider education).  This is true for many rare but serious events, and is the basis for the traditional “Morbidity and Mortality” conference.  It can also be a mechanism for leveraging peer pressure, such as public reporting of compliance with documentation standards.  In general, though, most QM activity should be kept ‘within the family’ and at the level of the practice rather than individual providers.  This is because most QM opportunities arise from problems with the system rather than isolated individual error. 

Judicious search of the anesthesia literature and the ASA website can reveal guidelines, recommendations and advice for addressing QM issues.  Many such documents are listed and summarized in the MADOM. 

Step Seven:  Re-measure, and automate the process. QM becomes easier over time, because trends in accumulating data make it easier to discern true problems from random variation.  Increasing experience increases physician confidence in the process, and the openness and utility of event review.  One goal of the QM Physician is to embed the process of measurement and reporting in the fabric of the practice in such a way that data capture and analysis become as automatic to your group as monitoring of a patient’s vital signs and changing the anesthetic depth.   

Step Eight: Participate in the AQI. Contribution of data to the National Anesthesia Clinical Outcomes Registry (NACOR) entitles a practice to receive quarterly benchmarking reports, making it easier to identify areas of good and bad performance. AQI membership is open to any anesthesiology practice in the US.  NACOR is populated by continuous passive collection of digitized information from participating groups, ranging from simple billing system information to sophisticated electronic hospital records. In addition to aggregated national data and peer-group benchmarking, participation in the AQI is intended to provide ASA members, practice groups, and healthcare facilities with an easy and effective means to meet regulatory requirements for QM and practice assessment. Information on joining the AQI is available at www.aqihq.org.

AQI Recommended Indicators (Updated for 2013)

These are the things you should report:

Business Indicators

• Cases done
  • By surgical service
  • By anesthesia type
  • By ASA class
  • By location
• Number of providers
  • By type (Physician, Resident, CRNA, AA, etc.)
  • By subspecialty training or group
• Total minutes billed
  • By surgical service
• Top ten cases done, and average duration

Process Indicators

• On-time starting percentage of first cases
  • By service / facility
• Cancellation rate
  • By cause and preventability
• PQRS measure compliance
  • Prophylactic antibiotic administration
  • Adherence to central line bundle
  • Normothermia in the PACU
• Documentation compliance (% of cases with completed QM records)
  • By location / service / provider
• Number of patient complaints

Clinical Outcome Indicators

• Number of cases completed uneventfully
• Number of each critical event occurring (by location/service):

Patient Experience Indicators

• Overall patient satisfaction
  • By Service/facility/patient type
• Rate of postoperative nausea and vomiting
• Adequacy of pain management in the PACU
• Patient complaints
  • By Service/facility/patient type

Consensus definitions of critical events can be found on the AQI website: www.aqihq.org under the tab for “Resources.”  Look for the document titled “CPOM Registry Data Set.”  These definitions were developed by the ASA Committee on Performance and Outcome Measurement.

To assemble the indicators listed above, an anesthesia practice QM program will need to electronically capture the following relatively short list of raw data:

• For each case done:
• Location (facility)
• CPT code(s)
• surgeon
• anesthesia provider(s)
• date
• time (or duration)
• anesthesia type (general, regional, sedation, combination, etc)
• ASA class
• PQRS compliance (yes/no/not applicable for each of three variables)
• Occurrence of a listed complication (yes/no, and which one)
• Patient survey data (satisfaction, PONV, pain questions)
• Documentation completed, including QM form (yes/no)
• Number of patient complaints received (obtain this from the facility and the surgeons as well as from your own office mail)

Alliance with the facility QM personnel can help to gather patient satisfaction and complaint data, as well as complications occurring beyond the immediate perioperative period.  Software programs have been developed to facilitate capturing these data elements, analyzing them, and reporting the indicators listed above.  Some of these resources are available in MADOM, while a list of commercial vendors solutions can be obtained from the AQI website.

Quality in your Practice Video

The following video is presented by Dr. Curry of Spectrum Medical Group. This the best description we have found of how to make good, ethical, profitable use of QM data in an anesthesia practice.
For full disclosure - The video describes the use of a commercial product.

Craig Curry, MD - AQI Quality Presentation - Using a Database in Private Practice from spectrummedgrp on Vimeo.

Sub-Specialty Specific Anesthesia Quality Registries

The SAMBA Clinical Outcomes Registry is a web-based database designed to assist ambulatory anesthesiologists track their own outcomes, compare with national benchmarks, and meet regulatory requirements.